Constipation in Adults

Aka: Constipation in Adults, Constipation, Constipation Red Flags

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II. Definitions

  1. Constipation
    1. Derived from latin constipare (to crowd together)
    2. Difficult stool passage
      1. Sensation of incomplete evacuation
      2. Straining at stool
    3. Decreased stool frequency
      1. Normal frequency difficult to define
      2. In U.S., 95% of people pass >3 stools per week
        1. Therefore, 3 or less stools per week is defined as Constipation

III. Physiology

  1. See Defecation

IV. Causes

  1. See Constipation Causes
  2. See Functional Constipation (most common cause)
  3. See Medication Causes of Constipation

V. History: General

  1. Stool History
    1. Consider Bristol Stool Scale to identify stool abnormalities
    2. Stool caliber
    3. Stool frequency
    4. Stool consistency
  2. Duration of Constipation
    1. Organic causes present as Acute Constipation
    2. Functional causes present as Chronic Constipation
  3. Age may direct causes
    1. Consider Hirschsprung's Disease in younger patients
    2. Consider Colorectal Cancer in older patients
  4. Medication History
    1. See Medication Causes of Constipation
    2. Laxative Abuse (Phenolphthalein, senna, castor)
  5. Family History
    1. Colon Cancer
    2. Inflammatory Bowel Disease
  6. Habits
    1. Dietary Fiber intake
    2. Clear fluid intake per day
    3. Caffeine intake
    4. Physical Exercise
    5. Ignoring urge to defecate
  7. Abdominal surgery history
    1. Risk of intra-abdominal adhesions

VI. History: Red flags suggestive of Organic Constipation (requires Colonoscopy)

  1. See Organic Constipation
  2. Age over 50 years old and no prior Colorectal Cancer Screening
  3. Acute or recent onset Constipation
  4. Weight loss (especially more than 10 pounds or 4.5 kg)
  5. Abdominal Pain or cramping
  6. Rectal Bleeding, Melena, heme-positive stool (Iron Deficiency Anemia)
  7. Nausea or Vomiting
  8. Rectal Pain
  9. Fever
  10. Change in stool caliber (narrowing)

VII. Exam

  1. General Physical Exam
    1. Signs of Hypothyroidism (skin dry, edema, pallor)
    2. Neurologic Exam
  2. Abdominal Exam
    1. Abdominal Mass
    2. Bowel sounds (high-pitched or absent)
  3. Perianal changes
    1. Hemorrhoids
    2. Anal Fissures
    3. Anal stenosis or stricture
  4. Digital Rectal Exam!
    1. Fecal Occult Blood Testing
    2. Rectal Mass
    3. Amount and consistency of stool in Rectum
    4. Stool leakage on Rectal Exam
      1. Suggests Fecal Impaction or Rectal Prolapse
    5. Severe pain on Digital Rectal Exam
      1. Suggests Anal Fissure or Hemorrhoids
    6. Anal sphincter tone
      1. Poor sphincter tone suggests neurologic deficit
      2. Anal Wink loss suggests sacral nerve deficit

VIII. Evaluation

  1. See Constipation Causes
  2. See Medication Causes of Constipation
  3. See Organic Constipation (Acute Constipation)
  4. See Functional Constipation (most common cause)

IX. Management

  1. No red flag symptoms or signs
    1. See Functional Constipation (Chronic Constipation)
    2. Treat empirically
    3. If no improvement consider Organic Constipation
  2. Red Flag symptoms or signs above suggest organic cause
    1. See Organic Constipation (Acute Constipation)

X. References

  1. Cheskin in Barker (1995) Ambulatory Medicine, p.476-81
  2. Sartor in Dornbrand (1992) Ambulatory Care, p. 221-5
  3. Arce (2002) Am Fam Physician 65(11):2283-90 [PubMed]
  4. Borum (2001) Prim Care 28(3):577-90 [PubMed]
  5. Wald (2000) Med Clin North Am 84(5):1231-46 [PubMed]

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